SCHOOL ANAPHYLAXIS ACTION PLAN (To be completed at the beginning of each school year and kept on file with the school nurse or office of the principal) Student s Name: Grade: DOB: School Campus: School Year: Parent/Guardian Name: Home phone: Address: Work phone: Emergency Contact Name Relationship Phone Physician student sees for allergy: Phone: Other physician: Phone: * * * * * * * * * * * * * * * * * * * * * * EMERGENCY PLAN * * * * * * * * * * * * * * * * * * If student complains of symptoms below or ingests or has contact with allergen listed: Stay with child Designate someone to call the nurse or other staff members trained to implement emergency plan (see below). Directly monitor student for not less than 30 minutes for symptoms indicated below. Contact parent. TO BE COMPLETED BY PHYSICIAN: Student is allergic to Emergency action for an anaphylactic reaction using medications listed below is necessary when this student has symptoms such as: a. Sneezing, wheezing, or coughing i. Dizziness and /or fainting b. Shortness of breath or tightness or chest; difficulty or absence of j. Involuntary bowel or bladder emptying breathing c. Itching, with or without hives, raised red rash in any area of body. k. Sense of impending disaster or approaching death d. Difficulty swallowing l. Rapid or weak pulse e. Swelling of eyes, lips, face, tongue, throat or elsewhere m. Skin flushing or extreme paleness f. Hoarseness n. Burning sensation, especially on face or chest g. Sweating and anxiety o. Blueness around lips, inside lips, eyelids h. Nausea, abdominal pain, vomiting, and diarrhea p. Loss of consciousness Steps to take during an anaphylactic episode: Administer medication listed as other, observe for improvement and proceed to emergency medications if symptoms are not relieved in minutes. Give emergency medication and call 911. Begin CPR for absent breathing/pulse 1. Emergency medication: A. Anaphylactic Medication N 8
2. Other medication: Additional instructions: These medications are prescribed for the time period until I give permission to my child s school to administer daily and emergency medications as necessary, in accordance with physician s instructions. I agree that the school nurse may discuss information related to the provision of care for my child with my physician. I also agree that information contained within may be discussed with related school staff for the provision of safe care. Parent/Guardian s Signature SELF-ADMINISTRATION OF ANAPHYLAXIS MEDICATION It is my professional opinion that (student s name) should be allowed not allowed to carry and self-administer the injectable emergency medication listed above while on school property or at school-related events. He/She has been instructed in the proper way to use of this medication. NOTE: Parent must provide additional medication to be kept in the school clinic. I agree with the recommendations of my child s physician as noted above and have informed my child that he/she may or may not carry his/her injectable medication while on school property or at school-related events. He/she has been instructed in proper use of this medication. I understand that I must provide additional medication to be kept in the school clinic. Parent/Guardian s Signature FOR SCHOOL CLINIC/OFFICE USE ONLY: If the school nurse is not available, the following staff persons are trained to initiate the emergency plan: School Nurse s Signature Principal s Signature N 8 09/01
09/01
SCHOOL ANAPHYLAXIS ACTION PLAN (Debe ser completado al principio de cada año escolar y guardado en la oficina de la enfermera o del director de la escuela) Nombre del Estudiante: Grado: Fecha de Nacimiento: Escuela: Año Escolar: Nombre del Padre/Guardián: Teléfono de la Casa: Dirección: Teléfono del Trabajo: Contacto en Caso de Emergencia Nombre Relación Teléfono Doctor que ve al estudiante para las alergias: Teléfono: Otro Doctor: Teléfono: * * * * * * * * * * * * * * * * * * * * * * EMERGENCY PLAN * * * * * * * * * * * * * * * * * * If student complains of symptoms below or ingests or has contact with allergen listed: Stay with child Designate someone to call the nurse or other staff members trained to implement emergency plan (see below). Directly monitor student for not less than 30 minutes for symptoms indicated below. Contact parent. TO BE COMPLETED BY PHYSICIAN: Student is allergic to Emergency action for an anaphylactic reaction using medications listed below is necessary when this student has symptoms such as: a. Sneezing, wheezing, or coughing i. Dizziness and /or fainting b. Shortness of breath or tightness or chest; difficulty or absence of j. Involuntary bowel or bladder emptying breathing c. Itching, with or without hives, raised red rash in any area of body. k. Sense of impending disaster or approaching death d. Difficulty swallowing l. Rapid or weak pulse e. Swelling of eyes, lips, face, tongue, throat or elsewhere m. Skin flushing or extreme paleness f. Hoarseness n. Burning sensation, especially on face or chest g. Sweating and anxiety o. Blueness around lips, inside lips, eyelids h. Nausea, abdominal pain, vomiting, and diarrhea p. Loss of consciousness Steps to take during an anaphylactic episode: Administer medication listed as other, observe for improvement and proceed to emergency medications if symptoms are not relieved in minutes. Give emergency medication and call 911. Begin CPR for absent breathing/pulse 1. Emergency medication: A. Anaphylactic Medication AISD N-8 02/02 gc
2. Other medication: Additional instructions: These medications are prescribed for the time period until Yo le doy permiso a la escuela de mi hijo/a para administrar medicamentos diarios y de emergencia tal como sean necesarios, de acuerdo con las instrucciones del doctor. Estoy de acuerdo conque la enfermera de la escuela se comunique con mi doctor para discutir la información relacionada con el suministro del cuidado de mi hijo/a. También estoy de acuerdo conque dicha información sea discutida con el personal de la escuela relacionado con el suministro de cuidados seguros. Firma del Padre/Guardián Fecha SELF-ADMINISTRATION OF ANAPHYLAXIS MEDICATION It is my professional opinion that (student s name) should be allowed not allowed to carry and self-administer the injectable emergency medication listed above while on school property or at school-related events. He/She has been instructed in the proper way to use of this medication. NOTE: Parent must provide additional medication to be kept in the school clinic. Yo estoy de acuerdo con las recomendaciones del doctor de mi hijo/a escritas arriba y le he informado a mi hijo/a de que él/ella puede o no puede llevar consigo sus medicamentos inyectables en la escuela o en eventos relacionados con la escuela. Él/ella ha sido instruido en la manera correcta de usar sus medicamentos. Entiendo que debo proveerle a la escuela medicamentos adicionales para que sean guardados en la clínica. Firma del Padre/Guardián Fecha FOR SCHOOLCLINIC/OFFICE USE ONLY: If the school nurse is not available, the following staff persons are trained to initiate the emergency plan: School Nurse s Signature Principal s Signature N 8 gc AISD
09/01